113 Bethlehem Rd OPERATION PERMIT FEvaluated
ice se nv
Davie County Health Department Number 220261 -1
�p fit•
210 Hospital Street
P.O.Box 848 umber.
Mocksville NC 27028 or. REPAIRPhone:336-753-6780 Fax:336-753-1680 .
Applicant: Paula Lewis Property Owner: Paula Lewis
Address: 113 Bethlehem Drive Address: 113 Bethlehem Drive
City: Advance City: Advance
State2ip: NC 27006 State/Zip: NC 27006
Phone#: (336)782-7601 Phone#: (336)782-7601
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
113 Bethlehem Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy,158, left on Redland Rd at the Old Store, then
right:on Bethlehem
#of Bedrooms:
#of People:
*Water Supply: NIA
*IP Issued by *System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert Saprolite System? QYes Flo
Design Flow: 3 6 0 'Dist ribution Type: GRAVITY-SERIAL Pump Required?
QYes QNo
Soil Application Rate: 0 2 7 5 *Pre Treatment:
Drain field
Nitrification Field 1 3 0 9 Sq.n• *System Type: INFILTRATOR QUICK 4 STANDARD
No. Orcin Lines 3 Installer:
Total
Total Trench Length: 3 3 0 ft. Certification#: 1107
Trench Spacing: — 9 Inches O.
C.
g *EHS:C.
Feet O.C. 2140-Nations.Robert
Trench Width: 3 Inches
Feet Date: 0 8 / 3 0 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Approval Status;
Inches
Maximum TrenchDepth: 3 6 ®,�Approrred 0 Disapproved
Inches
Maximum Soil Cover: 2 4 Inches
CDP File Number 220261 - 1 Septic Tank County ID Number:
'
Manufacturer. Lat.
(
Long:
STB:
Gallons: Installer
Date: Certification#:
*EHS:
*Filter Brand:
ST Marker. ❑ Yes ❑ No Date:
Reinforced Tank: ❑ Ye ❑ No Approval Sfatus
Piece Tank: ❑ Yes ❑ No ❑ Approved❑o Disapproved= = `
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: *EHS:
Date: Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No (Min.6 in.)
Reinforced Tank: _❑ Yes - ❑ No
Approval Status
D Approved 0 Disapproved
1 Piece Tank: ❑ .Yes _ ❑ No e ,-� --
Supply Line
FPiope
ize: inch diameter Installer.gth: feet CertificationShedule:
*EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No
; Approval Sfatus
[� Approved O Disapproved
Pump Requirement
Pump Type: Installer,
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval Status
PVC Unions [:3 Yes O No ❑ Aproved❑ Disapproved
Vent Hole ❑ Yes O No
Anti-siphon Hole El Yes 0 No
CDP File Number 220261 - 1 County ID Number:
Electric Equipment
NEMA4X Box or Equivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade [-] Yes El No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date: /
Approval Status
Alarm Audible ❑ Yes ❑ No
❑ Approved❑ Dlsapprovedj
-Alarm Visible ❑ ���es ❑�Wo
2140-Nations,Robert
*Operation Permit completed by:
Authorized State Agent:-� .---� � Date of Issue. 6 $ / 3 0 / a 0 1 6
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, ISA NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE IIA sewage septic system.
Rule.1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator.
N/A
Reporting Frequency By Certified Operator: N/A
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a homelbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit fora system required to be maintained by public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the ownerand systems operator,provisions that the contract shall be in effect for as tong as the
system is in use,and other requirements for the continued proper performance of the system. it shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie county Health Department CDP File Number: 22Q261 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Draiviint! Drawing Type: Operation Permit Scale: . ON A k
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CONSTRUCTION For office Use only
AUTHORIZATION "CDP File Number 220261 . 1
U11Davie County Health Department County ID Number:210 Hospital StreetEvaluated For. REPAIR
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 7 / 0 7 a 0 a 1
Applicant: Paula Lewis Property Owner: Paula Lewis
Address: 113 Bethlehem Drive Address: 113 Bethlehem Drive
Cky: Advance City: Advance
State2ip: NC 27006 StatefZip: NC 27006
Phone#: (336)782-7601 phone#: (336)782-7601
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
113 Bethlehem Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158, left on Redland Rd at the Old Store, then right
on Bethlehem
#of Bedrooms:
#of People:
'Water Supply: NiA
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally suitable Inches
Minimum Soil Cover. 1 a
Saprolite System? OYes @No - Inches
Design Flow: a 4 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 - a 7 5 Maximum Soil Cover: a 4 Inches
'System Classification/Description: 'Distribution Type:
Septic Tank:_ Gallons
'Proposed System: 1-Piece: OYes ONo
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 3 0 9
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 a y ft GPM—vs— ft. TDH
Trench Spacing: _ 9 Inches O .
@Feet O.C. Dosing Volume: _ Gallons
Trench Width:
— 3 _ @Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI OII 0111 OIV
Donn 7 of Z
CDP File Number 220261 - 1 County ID Number.
❑ Open Pump Systtm Sheet
Repair System Required:OYes ONo ONo, but has Available Space '
rDesign
System
Trench Spacing: Q Inches O.
ification: Q Feet O.C.
Trench Width: Q Inches
w: _ O Feet
Soil Application Rate: Aggregate Depth: inches
u
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type:
Total Trench Length: - Pump Required: OYes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit Issued(NCGS 130A-336(11)�If the installation has not been
completed during the period of validity of the Construction Permit,the Information submitted In the application for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit orConstruction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance;monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date:_
=Issued By: 2140-NaOons.Robert Date of Issue: 0 7 0 7 2 0 1 6
Authorized State Agent: Malfunction Log OYes '.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 220261 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 7 / 0 7 / 2 0 1 6
Q Inch
Drawing Drawing Type: Construction Authorization Scale: QBIock
ON/A
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CONSTRUCTION AUTHORIZATION
Davie County Health Department '
210 Hospital street CDP File Number: 22026'x" 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: .0 .7 / 0 7 / 2 0 1 6
Click below to import an image from an external location: DraW � pe'Construction Authorization
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Davie COUNTY
210 Hospital Street
P.O. Box 848
Mocksville NC 27028 TEL: 336-753-6780 FAX: 336-753-1680 Request ID: 67052
REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT
REQUEST DATE: 07/06/2016 TAKEN BY:
SECTION: N/A TYPE:
PROPERTY NUMBER: 220261 ASSIGNED TO: Nations, Robert
ESTABLISHMENT NUMBER:
PERSON OR PREMISES TO SEE: OWNER: Paula Lewis
Paula Lewis 113 Bethlehem Drive
113 Bethlehem Drive Advance , 27006
Advance NC, 27006
(33 6) 782-7601
REQUESTED BY: Homeowner HOME:
WORK:
Cell:
Additional Information:
CONDITION REPORTED:Drain Lines full
COMMENTS:
RECORD OF INVESTIGATION
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
DATE: HR/MT: COMMENTS
EHS:
EHS #:
ACT CODE:
Next Inspection Date: Status of Complaint: OPEN Resolved Date:
Complaintant Contacted: NO
f5v
s
• DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
• APPLICATION IP/ATC OSWW REPAIR
Name S TelephoneNumber
Address /1.2 1)/:
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot#
Directio a LAO iD 0,V_ &k y2e-
Date System Installed Name System Installed Under
Type FacilityNumber Bedrooms Number Pe o le Served
Type Water Supply Specific Problem Occurring ;N /iW&S
IVAI k-
Date Requested j '7-&-� Info Taken By Qmc&(
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
X DANIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST.
APPLICATION IP/ATC OSWW REPAIR
y �*me- Telephone� �S Number
Address BelhleI ip h�
Mailing Address (if different from above)
Email Address: ; !
Subdivision Name /Lot#
ti nS�
DirecTl f nN k 44t l ip S�� � O 5/d YC.
ty
Date System Installed �`(�7 ;�r ti. . Name System Installed Under S- hil, I
Type Facility {05G �' Number Bedrooms Number People Served
Type Water Supply f Specific Problem Occurring Delo /,v h wL' S
of it-r
Date Requested -�� Info Taken-By •�._ �1/hlL�t
THIS IS TO CERTIFY THAT;THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT.I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee L ` D6teL, REHS
Revisit Charge Date Reason ?�(/
Revised 2-2011
1